The Politics Of Health

Village-run health programs
in the Sierra Madre region of Mexico

One of the articles in Good Medicine (IC#39)
Originally published in Fall 1994 on page 50
Copyright (c)1994, 1997 by Context Institute

Project Piaxtla is a small, community-based health program in the mountains of western Mexico, the Sierra Madre. Today it is controlled entirely by local villagers, some of whom have been working with the program since it began in 1964. The project serves more than 100 small villages, some of them located two days on mule back from the training and referral center in the village of Ajoya. The mud-brick center is run by a team of experienced local health workers, who train and provide support for health workers from the more remote villages.

David Werner, a founder of Project Piaxtla, continues to be actively involved in the project. In this interview he explains why health work is political work, and how the North American Free Trade Agreement (NAFTA) has become the biggest challenge yet to their progress.

Can you explain the shifts from curative care to preventive measures to political action that have occurred in Project Piaxtla?

David: The program began with a focus on curative care because that’s what the people wanted. A mother who has a sick child is concerned with getting the child treated. After the child is better, she can be more open to ideas about prevention.

Soon the people in the community began to notice the same problems were being treated, but they kept coming back. So the health workers moved into the preventive area, getting vaccines from health authorities in the cities. They went back to their villages and introduced vaccination programs, water systems, and latrines. They found that 70 percent of the people were interested in family planning, so they introduced safe options for birth control.

With these preventive measures, health improved to a certain extent, but there were still a lot of children dying, primarily of undernutrition. The reason they were dying was primarily the land tenure system. The wealthy and more powerful families took advantage of the poorer families by exploiting their labor and charging impossible interest rates for corn and tools. So the village health workers focused on helping poor people increase their economic base and gain more control over the social and political factors influencing their lives.

Kathryn: How did they do that?

David: They focused their efforts on projects where the poor campesinos were systematically cheated, mistreated, or exploited. They demanded that the owner of the local bus route lower fares to the legal rates, the village women organized to shut down the public bar (to reduce drunkenness, violence, and undernutrition), they organized a protest to take control of the village water supply from a wealthy man and to introduce a public water system controlled by the community, and they began a cooperative maize (corn) bank.

Kathryn: How did the cooperative maize bank work?

David: Typically in Mexico, as in so many other countries, at planting time the poor run out of their basic food supply. Often they don’t have enough seed to plant, so they borrow from the rich. In Mexico, for every sack of corn they borrow at planting time, they have to give back three to four sacks at harvest time. This unfair loan system is one of the reasons for the exodus of the poor farmers to the slums of the cities. Once a farmer begins to borrow he has to give up a lot of his harvest, so he runs out even earlier the next year.

The health workers and the farmers managed to get a parcel of river bottom land (the rich, alluvial flat lands that produce the best harvest and have mostly been held by a few wealthy landowners). They planted on this land and gradually built up a cooperative corn bank, which would lend out corn for very low interest – 25 percent compared to 300 percent charged by the land owners.

But the biggest difference was that the gains didn’t go into any private property or pockets. The gains benefited the borrowers, and the basic stock gradually grew until eventually the bank was so successful it made itself obsolete. Because they didn’t have to pay off so much corn every year, the campesinos saved enough so they didn’t have to borrow.

Kathryn: Can you explain how land distribution affects health?

David: Before the revolution in 1910, poor families had to choose to either plant the steep mountainsides using the slash-and-burn method – hard work for small yields – or to work the good land held by the big landholders, and turn over half of their harvest for the right to use the land. Either way, the amount of grain they ended up with often wasn’t enough to last for the season, and they and their children would go hungry.

The heart of the 1917 Constitution (which resulted from the Mexican revolution) was its land reform program. To prevent the return of huge plantations, limits were placed on the legal size of property holdings. Also, the famous ejido system was set up: The local farmland was divided equitably among all of the families. Each family would receive provisional title to their parcel, could farm it and benefit from the produce as they chose. But ultimate ownership stayed with the ejido, which was set up by the people of several villages. The family could not sell its parcel nor have it seized for unpaid debt. This protected small farmers from losing their land.

Kathryn: How did the people you worked with reclaim their land?

David: Through the success of projects like the corn bank, the campesinos eventually mustered enough strength and unity to tackle one of the biggest, highest risk issues contributing to hunger and poor health, which was the distribution of land. They began methodically to reclaim large holdings, divide them up, and then demand legal titles.

At first they met strong resistance. The agrarian reform authorities at the state level were accustomed to generous bribes from the land barons and either turned a deaf ear or made promises followed by endless delays. Not until a group of campesino health workers traveled to Mexico City and hounded the federal offices of the Reforma Agraria were orders passed down, and state officials reluctantly issued ejidal land titles to the group of small farmers.

Encouraged by the farmworkers’ victory, a widening circle of landless campesinos in the Sierra Madre began invading large land holdings and demanding their constitutional rights. Over the next 15 years, they succeeded in redistributing and gaining legal title to more than 50 percent of the good riverside land.

Both the food supply and economic base of these poor families were substantially improved, contributing to a visible improvement in health. Serious malnutrition in infants became uncommon, parents began to look toward the future, rather than just for the next meal. More families could afford notebooks and pencils, so more children stayed in school.

Kathryn: How has the North American Free Trade Agreement (NAFTA) affected the victories of the campesinos?

David: In preparation for NAFTA, the US government pressured the Mexican government into annulling the agrarian reform statutes from their constitution. The power structure in Mexico was more than willing to do this because they had been violating the ejido laws for a long time anyway. Land owners have very close ties to government there.

The US government insisted that the agrarian reform statutes conflicted with free trade. They wanted to open the way for big US agri-businesses to buy huge parcels of land in Mexico. As a result, the land will be concentrated into fewer hands, and millions of peasants will be forced off their land and into the growing slums of cities where they will add to the unemployed.

Over the last 10 years, the real wages of Mexican workers have dropped by 40 percent. It takes four minimum wages to adequately feed a family of five. An agreement such as NAFTA will push wages down further, make it harder for families to feed their children, and ultimately cause diseases of undernutrition that will lead to more deaths.

Kathryn: How do the various health workers support each other? Do they have any way to take on the bigger issues, like NAFTA?

David: A network of community-based health programs from Mexico and Central American countries hold educational interchanges to examine the situations in which their health problems exist, and to discuss the causes. The health care workers learn strategies from each other about how to move their communities towards more equitable living situations.

Produsset is the name of the association of community-based health programs in Mexico. They have held meetings on NAFTA and other economic power plays that have worsened poverty in their country. They discuss short-term strategies, such as the cooperative corn bank, and long-term solutions, that have to do more with the sort of thing that happened in Chiapas.

Kathryn: What is the relationship of the Chiapas uprising to the effort you’re describing?

David: The peasant uprising in Chiapas was symbolically launched on January 1, 1994, the day NAFTA went into effect. The insurrection lasted only four days, but brief as it was, the occasion drew national and international attention to some well-justified demands. More than 70 percent of the nation supported the uprising, and as a result, the government changed some of the agrarian policies it put into effect during NAFTA negotiations. As a result of the pressure from Chiapas, the government passed a ruling that allowed communities already formed as ejidos to be able to vote on whether they would keep their ejido. However, government disinformation is being spread to try to trick ejido communities into believing that under NAFTA for the first time land will be completely theirs, and that they will have access to government loans available for land development and fertilizers. They see the peso signs and are tricked into ending the ejido and privatizing the land. The loans that sound so attractive are what cause people to lose the land because they go into debt they can’t pay back, then the lenders confiscate the land for payment. Within the ejido system, that cannot happen because the farmer’s home community owns the land.

Kathryn: Have the Project Piaxtla outreach efforts made a difference?

David: Awareness raising is most important. In the Sierra Madre (the mountains that are home to Project Piaxtla), almost all of the people in communities that have been involved in discussions about NAFTA understand what would happen if they give up their ejidos, and they have voted to keep them. In other parts of Mexico, where there has been less sociopolitical education, the farmers have been deceived into giving up their ejido land rights.

Kathryn: What can US citizens do to have a positive impact for the villagers?

David: A very important thing for US citizens and especially workers to realize is that they should join forces with Mexican workers, rather than be divided against them. With NAFTA, as big American factories go south of the border for cheap labor, a lot of Americans are losing jobs. As millions of poor workers are forced off their land and unemployment rises, an increasing flood of Mexicans will come into the US.

Rather than fight each other, Americans and Mexicans need to address the real reasons for their problems.

Kathryn: What’s happening with Project Piaxtla today?

David: The health program now is not anything like what it used to be because the government has come in with its own health programs. The village-controlled health programs are seen as a potential threat. One positive outcome has been that the health workers are freed up to put energy into community organizing and land issues, which in the long run have more to do with improving health than preventive or curative care.


David Werner is the author of several books on village health, including
Helping Health Workers Learn and Where There is No Doctor. He is a founding member of the International People’s Health Council, a worldwide coalition committed to working for the health and rights of disadvantaged people – and ultimately of all people. The vision of the IPHC is to advance toward health for all people, viewing health in the broad sense of physical, mental, social, economic, and environmental well-being. IPHC is based in Nicaragua and has regional offices around the world.

Werner is also a founding member of HealthWrights, a nonprofit organization committed to advancing the health, basic rights, social equality, and self-determination of disadvantaged persons and groups. They believe that health for all people is only possible in a society where the guiding principles are sharing, mutual assistance, and a respect for cultural and individual differences.

For more information on these programs, books, and the Sierra Madre newsletter, write to: 964 Hamilton Ave., Palo Alto, CA 94301, or call HealthWrights at 415/325-7500.

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